Ultrasonography on the labour ward

Ultrasonography is one of the most important technologies introduced in obstetrics over the last 30 years. Its use on labour ward has changed the obstetrical practice. Literature describing its applications is large. Therefore, the objective of this article is to present a review of the literature on the potential interest of ultrasonographic use on labour ward. Transvaginal ultrasonography, in the case of premature labour, has allowed an adaptation of the management. Use of ultrasonography instead of the Bishop score seems to be logical considering the superiority of its diagnostic value and the reduction of interindividual variability. Nevertheless its advantages must not be overestimated. Use of ultrasonography to check fetal presentation might be justified in case of clinical doubt, a systematic use being difficult in case of clinical certainty. On the other hand, it seems logical to use it routinely before an instrumental extraction. Transabdominal ultrasonography seems to be generally more accessible than transvaginal ultrasonography, which might be useful in case of fetal engagement. Ultrasonography on labour ward finds its indication in many cases: fetal heart recording difficulties or abnormalities, before induction, engagement diagnosis, multiple pregnancies, evaluation of the amniotic fluid index, fetal weight estimation, vaginal bleeding and unknown pregnancy. Thus, ultrasonography is more and more present on labour ward, and practitioners should use it as a complementary tool for investigation rather than a replacement for their clinical skills.     

The best of both worlds--parents' motivations for using an alongside birth centre from an ethnographic study

Objective and design

an ethnographic study was undertaken in a birth centre to explore the model of care provided there from the perspectives of midwives and parents.

Setting

a five birthing-room, alongside, inner-city, birth centre in England, situated one floor below the hospital labour ward, separately staffed by purposively recruited midwives.

Participants

around 114 hours were spent at the birth centre observing antenatal, intrapartum and postnatal care; 11 in-depth interviews were recorded with parents after their baby's birth (four with women; seven with women and men together), including three interviews with women who transferred to the labour ward, and 11 with staff (nine midwives and two maternity assistants).

Findings

most women and men using the birth centre perceived it as offering the ‘best of both worlds’ based on its proximity to and separation from the labour ward. It seemed to offer a combination of biopsychosocial safety, made evident by the calm, welcoming atmosphere, the facilities, engaging, respectful care from known midwives and a clear commitment to normal birth, and obstetric safety particularly because of its close proximity to the labour ward.

Key conclusions and implications for practice

this alongside birth centre provided a social model of care and appealed strongly to a group of parents; similar birth centres should be widely available throughout the NHS.     

Midwives' beliefs and concerns about telephone conversations with women in early labour

Objective

to explore midwives' concerns, experiences and perceptions of the purpose of telephone contacts with women in early labour.

Design

a qualitative design based on interpretive phenomenology.

Setting

two Maternity Units in the Midlands of England.

Participants

three focus groups of labour ward midwife co-ordinators and labour ward midwives and nine in-depth interviews of midwives, obstetricians and labour ward receptionists.

Findings

the principal finding was that midwives are trying to reconcile gatekeeping of labour wards with individual support for women and these two aspects are often in conflict. Women experiencing prolonged or painful early labour often expect to be admitted to labour wards whereas midwives operate from a belief that women should only be accepted onto labour ward in active labour. They hold this view because labour wards are busy places and being admitted early contributes to unnecessary medical intervention.

Key conclusions

because midwives are trying to reconcile the two conflicting priorities of responding to women's needs and protecting the labour ward from inappropriate admissions, the potential always exists for women's needs to be ‘not heard’ or marginalised.

Implications for practice

the primary recommendation is that early labour telephone triage should be a discrete service, staffed by midwives who have been trained for this service, working independently of labour ward workloads.     

Swedish midwives' rating of risks during labour progress and their attitudes toward performing intrapartum interventions: a web-based survey

Objective

to study how Swedish midwives working in low-risk labour ward units rate intrapartum risks compared to their midwifery colleagues working in standard care labour wards. A second aim was to describe midwives' attitudes toward performing different types of interventions during a normal labour.

Design

an explorative study was carried out in 2009, using a web-based questionnaire containing 31 questions on midwives' risk ratings and attitudes to interventions during labour, as well as personal comments.

Setting

four labour ward units in Stockholm, Sweden. Two labour ward units with expected normal deliveries (‘low-risk’) and two standard care units with all types of deliveries.

Participants

seventy-seven registered clinically practicing midwives.

Findings

midwives in all units stated that factors to be considered for risk estimation were: previous delivery outcome, result of cardiotocography test (CTG) on admission to labour ward and quality of amniotic fluid. Midwives working at the low-risk units preferred to be more expectant during normal birth than their colleagues working at the standard care units. Examples of this were regarding second vaginal examination during labour (p=0.001) and/or amniotomy (p=0.012). Furthermore, midwives working at the low-risk units more often considered that first-time mothers could give birth without epidural analgesia during labour (p=0.019) and that the labouring woman should be encouraged to push according to her own spontaneous urge (p=0.040). Midwives at low-risk units were more reluctant to use an intravenous vein catheter than their colleagues at standard care units (p=0.001) and also to use oxytocin in order to augment contractions (p=0.013). Further, the open-ended question showed that attitudes to different types of interventions differed between midwives working at low-risk units or the standard care units working with all types of deliveries.

Conclusion

the Swedish midwives estimated risks similarly regardless of whether they worked in low-risk or in standard care units, but midwives working at low-risk units reported that they perform less routine interventions and have a more expectant attitude towards performing interventions.     

The pressure is on: midwives and decubitus ulcers

Research regarding pressure area care and management in nursing extends back many years, but remains relevant and cited today. With relevant knowledge, midwives can help prevent the development of pressure sores in the maternity setting. Clinical governance and risk management should ensure that the incidence and occurrence of pressure sores in the midwifery arena is reported and fed into appropriate audit analysis at local, regional and national levels. Midwives need to seriously consider the implications of modern midwifery care and management in relation to the development of pressure sores in our population. Labour suite, high dependency, ward and community areas should include guidelines for the prevention, treatment and management of pressure sores, including mattress policies. Prophylactic measures and assessment scores could be incorporated into partogram documentation in the labour suite and as part of postoperative documentation in the ward environment for women who have undergone caesarean section. Trusts may find that a link midwife liasing with tissue viability nurses proves beneficial. Community midwives should forge links with the district nursing services in their Primary Care Trust areas with regard to developing or adapting tools. Knowledge of pathophysiology, prophylaxis and subsequent management of decubitus ulcers in maternity care is sadly lacking in midwifery textbooks. Future authors and editors should include this subject and it should feature more prominently in midwifery education curricula. It is clear that there is much work to be done in this area, both educationally and clinically. Further research is required to evaluate pressure prevention strategies in the midwifery arena, including the increasing provision of one-to-one care in labour suite units. Improvements in the appropriate prevention and subsequent treatment and management of pressure sores will benefit women and help save the NHS hundreds of thousands of pounds in treatment and litigation costs.     

Obstetric Team Care by a Private Midwife and Obstetrician—A Pilot Trial

Autonomous obstetric care by either midwife or doctor excludes the complementary expertise of each other. However, in the present Australian hospital system midwives are usually unable to provide continuity of antepartum, intrapartum and postpartum care to the individual patient and thus are less able to accept ongoing clinical responsibilities or provide satisfactory psychological support to the patient. A pilot trial was instituted to assess the practicality of team care by an obstetrician and a midwife where the midwife, having joined with the obstetrician in the care of the patient at all antenatal visits, attended the patient on her admission to the labour ward until 1 hour after her delivery. This personalized midwifery service did not, in this trial, involve the midwife in duties or responsibilities greater than those of the normal labour ward staff but provided the patient with continuity of care and support by a midwife known to the patient throughout her labour and delivery. The midwife visited the patient twice postnatally. Sixty private patients entered the trial and 56 were attended by the midwife in labour. The mean length of attendance of the midwife in the labour ward was 6.6 hours (range 2-14 hours). The mean length of labour in the hospital was 5.2 hours. There was an apparent reduction in analgesic requirements in the trial patients compared to the concurrent rates in the hospital. All patients in the trial were very enthusiastic about the service, the words 'confidence' and 'security' recurring in their later comments. The service was well accepted by the rostered labour suite staff after an initial orientation programme.(ABSTRACT TRUNCATED AT 250 WORDS)     

A comparative study in Stockholm,Sweden of labour outcome and women's perceptions of being referred in labour

OBJECTIVE: to study the outcome of labour and women's perceptions of being referred after onset of labour. DESIGN: a comparative study carried out between October 1998 and April 1999. SETTING: prospective parents in Stockholm, Sweden are offered a choice of which of the five hospitals in which they want to give birth. In reality, there is a lack of maternity beds in Stockholm to implement this policy and therefore nearly 10% of labouring women are being referred during labour. PARTICIPANTS: the study population was selected from one of the five hospitals. Included in the study were 266 labouring women, with a 37-42 weeks uncomplicated pregnancy, fetus presenting by the vertex and spontaneous onset of labour. During pregnancy, all the women had chosen the same labour ward where they planned to deliver. However, at the onset of labour half of the women, case group I (n = 133) were referred to another maternity unit due to lack of space in the labour ward. For every referred woman a control woman matched for age, parity and date of delivery was selected, with the same inclusion criteria, except being referred, control group II (n = 133). METHODS: a questionnaire with closed and open questions was posted to the women after birth and used to collect quantitative and qualitative data on the outcome of labour and the women's perceptions of referral during labour. FINDINGS: routines such as epidural analgesia (EDA) (p<0.002), episiotomies (p<0.015) and morphine/pethidine during labour (p<0.023) were more common in the referred group. The women in the referred group considered to a higher extent that referral during labour had affected their emotional state (p<0.001). Women in both groups had been worried during pregnancy by the thought of having to be referred when labour had started and the referral had caused practical problems, stress and a feeling of not being welcome in the referral labour ward. KEY CONCLUSION AND IMPLICATIONS FOR PRACTICE: referral during established normal labour may affect labour outcome, and the possibility that they may be referred worries women during pregnancy. Maternity policies and practices should be organised so that caring goals, such as continuity of care and women's' participation in birth planning, can be met.     

Negotiating credibility: first-time mothers’ experiences of contact with the labour ward before hospitalisation

Objectiveto explore Norwegian nulliparous women's experiences of communication and contact with midwives at the labour ward in the early phase of labour.Designa qualitative study based on in-depth interviews.Participants17 women expecting their first baby.Findingsfour themes that emerged in the collected material seem to be central to how the labouring women decided to make contact with the labour ward and how they experienced this contact with the staff: (a) negotiating on two fronts, (b) avoiding being sent home, (c) searching for regularity, and (d) experiencing vulnerability.Conclusionsthe study shows how women in labour for the first time negotiate their credibility with midwives through the requisite pattern of regularity, and also shows their vulnerability in attempting to avoid being sent home from hospital because it is ‘too soon’ to be admitted. It also argues that the midwifery profession is ambivalent about the paradigm to which it conforms in its contact with women in early labour.Implications for practicethe findings of this study show that the way in which questions are asked in this phase is very important. Midwives should be aware that if they only ask the ‘standard question’ related to the pattern of contraction regularity, they might lose vital information and also deprive the woman of the chance to verbalise her experiences and her needs as she perceives them. If the focus is shifted from the rigid instructions that women are given to an emphasis on the women's actual experiences, the need for negotiation will probably diminish. The task of assessing and evaluating women in early labour need not necessarily be performed inside the ordinary labour ward, but may be done in a more home-like environment outside the hospital or in the woman's home.     

Mobility and maternal position during childbirth in Tanzania: an exploratory study at four government hospitals

BACKGROUND: Emerging research evidence suggests a potential benefit in being upright in the first stage of labour and a systematic review of trials suggests both benefits and harmful effects associated with being upright in the second stage of labour. Implementing evidence-based obstetric care in African countries with scarce resources is particularly challenging, and requires an understanding of the cumulative nature of science and commitment to applying the most up to date evidence to clinical decisions. In this study, we documented current practice rates, explored the barriers and opportunities to implementing these procedures from the provider perspective, and documented women's preferences and satisfaction with care. METHODS: This was an exploratory study using quantitative and qualitative methods. Practice rates were determined by exit interviews with a consecutive sample of postnatal women. Provider views were explored using semi-structured interviews (with doctors and traditional birth attendants) and focus group discussions (with midwives). The study was conducted at four government hospitals, two in Dar es Salaam and two in the neighbouring Coast region, Tanzania. MAIN OUTCOME MEASURES: Practice rates for mobility during labour and delivery position; women's experiences, preferences and views about the care provided; and provider views of current practice and barriers and opportunities to evidence-based obstetric practice. RESULTS: Across all study sites more women were mobile at home (15.0%) than in the labour ward (2.9%), but movement was quite restricted at home before women were admitted to labour ward (51.6% chose to rest with little movement). Supine position for delivery was used routinely at all four hospitals; this was consistent with women's preferred choice of position, although very few women are aware of other positions. Qualitative findings suggest obstetricians and midwives favoured confining to bed during the first stage of labour, and supine position for delivery. CONCLUSIONS: The barriers to change appear to be complicated and require providers to want to change, and women to be informed of alternative positions during the first stage of labour and delivery. We believe that highlighting the gap between actual practice and current evidence provides a platform for dialogue with providers to evaluate the threats and opportunities for changing practice.     

Consumer interest in alternatives to physician-centred hospital birth in Ottawa

A survey of 1109 women who delivered in a hospital or at home in a major city in Canada was conducted. The women were asked to respond to questions concerning the type of health professional they would like to provide reproductive care. The choices they were offered were: midwife, obstetrician, general practitioner or nurse, or a combination. Respondents were also asked to identify if they had an interest in an alternative such as a birthing room, birthing centre or home birth, to hospital labour ward care. Almost 60% of women were interested in some form of midwifery care with the major emphasis placed on counselling and support. Of the women who expressed an interest in midwifery services a large number elected for that service to be shared with an obstetrician. Women who were older and had achieved a high level of education were more interested in midwifery services than other women. If given choices of a hospital labour, birthing room, birthing centre or home birth 53% of women would choose to give birth in a hospital labour ward. A major reason for this choice was the accessibility of epidural analgesia. The majority of women who had experienced a home birth would make the same choice again. There was a strong positive association between interest in using midwifery services and interest in a birthing centre and home birth.     

Ultrasonography on the labour ward

The role of fetal ultrasonography in the antepartum period is well established. Its utility on the labour ward - either intra-partum, just prior to labour or post-partum - is less clear however. Its current application on the labour ward ranges from simple determination of fetal position to the more complex assessment/prediction of labour progress to appraising fetal physiological responses to intrapartum stress. Unfortunately, established guidelines for the appropriate implementation of these techniques appear to be lacking. Here, we review the current evidence-base for the clinical application of ultrasound on the labour ward and suggest future research directions.     

Failed Caesarean Section: An Obstetrician's Nightmare

EDITORIAL COMMENT: In medicine, human judgment is fallible, but obstetrics is the discipline in which an error of judgment is most rapidly revealed, to the obstetrician, the patient and the labour ward staff, due to the unpredictability of the duration of labour and imminence of delivery in any individual patient. When the editor was a house officer he was called to the antenatal ward because a multipara, near term had abdominal pain. Vaginal examination revealed an undiluted cervix, but within the minute or so it took a walk to the handbasin to wash his hands the woman had delivered a live baby into the bed. It is always wise, and should be a routine. unless operating in haste for an emergency such as bleeding from placenta praevia, to perform a vaginal examination after anaesthesia is established before commencing Caesarean section in a woman in labour. The editor has performed many safe easy-forceps deliveries in this circumstance, in theatre, in women in whom Caesarean section was planned for cephalopelvic disproportion with or without fetal distress. This finesse is more important if the consultant has agreed to perform a Caesarean on the findings recorded by others, but the fact remains that labour and delivery can accelerate most unexpectedly. We accepted this case report for publication, not merely because it is the first such case reported, but also for the opportunity it provided to stress to readers the need for final evaluation of the stage of labour before Caesarean section, when the conditions are most favourable for assessment. Nonetheless, as this case tells us. it is possible for labour and delivery to proceed faster than the obstetrician can perform a Caesarean section.     

Women's perceptions of pain and discomfort after childbirth in Angola

Prophylactic treatment against postpartum haemorrhage is a widely investigated area and injection of Oxytocics has been considered as the best choice. The occurrence of postpartum pain and discomfort was studied in a population of birthing women in an overcrowded labour ward in Angola where the oxytocin-filled device Uniject was used. This study indicates that birthing women's perceived postpartum pain increases with parity and during breastfeeding, but does not confirm that injection of oxytocin increases pain and discomfort. This is an important finding, since it might facilitate the introduction of a management practice, likely to reduce haemorrhage-related maternal morbidity and mortality after delivery in underprivileged populations. The birthing women were, by and large, satisfied with the care and treatment provided, but the encounters with midwives seem to vary in quality. Further investigation is needed to elucidate parturient women's experience of postpartum pain and their perceptions of the quality of care and treatment.     

A randomized controlled trial comparing midwife-managed care and obstetrician-managed care for women assessed to be at low risk in the initial intrapartum period.

OBJECTIVE: To compare the efficacy of midwife-managed care and obstetrician-managed care for women assessed to be at low risk in the initial intrapartum period. METHODS: 1,050 women assessed to be at low risk on admission to labour ward in the Prince of Wales Hospital participated in this study. By computer-generated random allocation, 563 (54%) women were assigned to Group A (experimental) under midwifery care, and 487 (46%) women to Group B (control) under obstetrician care. The outcomes and complications between the 2 groups were compared. Data were analyzed by 2 x 2 contingency tables and Chi-square. RESULTS: 150 (26.6%) women in the experimental group were taken over by the obstetricians. 46 (30.7%) women were transferred to obstetrician-management for the preference of epidural analgesia. The other reasons for taken over the remaining 104 (69.3%) women were fetal distress, poor progress of labour, complications in first or second stage of labour. The experimental group had less oxytocic augmentation (Chi-square = 7.49, p = 0.006) and the insertion of intravenous infusion (Chi-square = 5.34, p = 0.02). Both groups had similar outcomes on normal delivery, operative vaginal delivery, caesarean section and complications. CONCLUSIONS: Midwife-managed care is as safe as obstetrician-managed care for women who were assessed to be at low risk in the intrapartum period. Routine visit by obstetrician is not necessary and the midwives are able to detect complications in the course of labour and alert the obstetrician for taking the necessary action.     

Transforming intrapartum care: Respectful maternity care

Respectful maternity care is recommended by the World Health Organization and refers to care that maintains dignity, privacy, confidentiality, ensures freedom from harm and mistreatment, and enables informed choice and continuous support during labour and childbirth. In this paper, we review the evidence of respectful maternity care and discuss considerations for professional practice for health care providers. While there is limited evidence on what type of interventions can improve respectful maternity care, promising skills development for providers has included training on values, transforming attitudes, and interpersonal communication. Within a health facility, enabling environments may be created by setting up quality improvement teams, monitoring experiences of poor treatment, mentorship, and improved working conditions for staff. In order to provide respectful care, health facilities and health systems must be structured in a way that supports and respects providers, and ensures adequate infrastructure and organisation of the maternity ward.     

Intrapartal care documented in a Swedish maternity unit and considered in relation to World Health Organization recommendations for care in normal birth

OBJECTIVES: To describe documented intrapartal care in relation to the World Health Organization (WHO) recommendations for care in normal birth, and to compare intrapartal care for pregnant women at low and high risk in a conventional maternity unit. DESIGN: Retrospective examination of 212 consecutive childbirth records using an audit instrument developed from WHO's recommendations. SETTING: A conventional maternity unit in Western Sweden. FINDINGS: Practices that are demonstrably useful and should be encouraged were mostly documented, except for physical assessments, such as pulse and temperature and emotional aspects. Vaginal examinations were carried out more often than recommended, and fetal heart rates were seldom monitored intermittently. Practices classified as harmful, practices with insufficient evidence and practices frequently used inappropriately, were used to a large extent. There were high rates of interventions regardless of the women's risk level. The interventions were carried out without a rational documented indication. According to the documentation, only two-thirds of the women were in active labour on admission to the labour ward. CONCLUSION AND IMPLICATIONS FOR PRACTICE: The recommendations from WHO were only partly adhered to. The instrument is considered useful for systematic audit of documented intrapartal care, and may help to identify areas in need of improvement. Improvements suggested by this study were as follows: inclusion of emotional aspects in the documentation, differentiation in cardiotocographic (CTG) surveillance for women at low and high risk, documentation of explicit indications for interventions and guidelines for admission to the maternity unit.     

The use of a birthroom: a randomized controlled trial comparing delivery with that in the labour ward

A randomized controlled trial of two environments for delivery was conducted at Queen Charlotte's Maternity Hospital. A total of 253 parous women expecting to have a labour ward delivery were invited to participate in the trial but only 148 agreed. These women were randomly allocated to be delivered either with standard labour ward management (n = 72) or in the birthroom--a small bedroom decorated in a homely manner, without facilities for epidural analgesia or electronic fetal monitoring (n = 76). Eleven women in the birthroom group and 10 in the labour ward group withdrew from the trial before labour and four were transferred from the birthroom to the labour ward when in labour. A questionnaire sent in the postnatal period to the women who completed the trial was returned by 80%. In the birthroom group there was significantly (i) decreased admission-to-delivery interval (ii) less analgesia (iii) more freedom of movement (iv) less suturing (v) increased rooming-in. No difference was found in the assessment of difficulty of labour nor in the method of subsequent infant feeding.     

Swedish women's experiences of seeking care and being admitted during the latent phase of labour: a grounded theory study

Objective

to gain a deeper understanding of how women who seek care at an early stage experience the latent phase of labour.

Design

a qualitative interview study using the grounded theory approach.

Setting

the study was conducted at a hospital in the southwestern part of Sweden with a range of 1600–1700 deliveries per year. The interviews took place in the women's homes two to six weeks after birth.

Participant

eighteen Swedish women, aged 22–36, who were admitted to the labour ward while they were still in the latent phase of labour.

Findings

‘Handing over responsibility’ to professional caregivers emerged as the core category or the central theme in the data. The core category and five additional categories formed a conceptual model explaining what it meant to women being admitted in the early stage of labour and their experiences of the latent phase of labour. The categories, which all related to the core category, were labelled: (1) ‘longing to complete the pregnancy,’ (2) ‘having difficulty managing the uncertainty,’ (3) ‘having difficulty enduring the slow progress,’ (4) ‘suffering from pain to no avail’ and (5) ‘oscillating between powerfulness and powerlessness.’

Conclusions and implications for practice

findings indicate that women being admitted to the labour ward in the latent phase of labour experienced a need for handing over responsibility for the labour, the well-being of the unborn baby, and for themselves. Midwives have an important role in assisting women with coping during the latent phase of labour, and in giving the women opportunity to hand over responsibility. This care should include validation of experienced pain and confirmation of the normality of the slow process, information and support.     

Satisfaction and the three C's: continuity, choice and control. Women's views from a randomised controlled trial of midwife-led care

Objective 1. To explore whether there are differences in women's satisfaction with care in a midwife-managed delivery unit compared with that in a consultant-led labour ward. 2. To compare factors relating to continuity, choice and control between the two randomised groups.
Design A pragmatic randomised controlled trial.
Setting Aberdeen Maternity Hospital, Grampian.
Sample 2844 women, identified at booking as low risk, were randomised in a 2:1 ratio between the midwives' unit and the labour ward.
Main outcome measures Satisfaction, continuity of carer, choice, and control.
Results Satisfaction with the overall experience did not differ between the groups. Satisfaction with how labour and delivery was managed by staff was slightly higher in the midwives' unit group, but this did not reach the 0.1% level of significance. Women allocated to the midwives' unit group saw significantly fewer medical staff and were less likely to report numerous individuals entering the room. They were more likely to report having had a choice regarding mobility and alternative positions for delivery and were significantly more likely to have made their own decisions regarding pain relief.
Conclusions The issues surrounding the measurement of satisfaction with childbirth need further investigation. Until this area is clarified it would be unwise to use an overall measure of satisfaction as an indicator of the quality of maternity service provision. In particular, the current measures are not sensitive enough to examine the specific factors which affect women's satisfaction. Further research is required to assess which factors are important to women if they are to have a positive experience of childbirth and how these priorities change over time.